Incidence of tethered cord syndrome in neurofibromatosis types 1 and 2 pediatric patients: a population-level analysis

PURPOSE

Tethered spinal cord syndrome (TCS) is characterized by cutaneous attachments on the filum terminale that stretch the spinal cord, leading to musculoskeletal and urogenital sequelae. While the neurocutaneous associations with TCS remain undefined, a recent study reports a high incidence of TCS among a pediatric neurofibromatosis (NF) cohort. This present study utilizes a population-level database to estimate TCS incidence among pediatric patients with neurofibromatosis types 1 and 2 (NF1, NF2).

METHODS

The TriNetX Research Network was queried to identify patients diagnosed with NF and/or TCS before the age of 21. Symptomatic TCS requiring surgical intervention was identified using corresponding procedural codes within 12 months following TCS diagnosis. Odds ratios (OR) were calculated to measure the associations of NF1/NF2 with TCS.

RESULTS

19,426 pediatric NF patients were evaluated (NF1: 18,383, NF2: 1042). The average ages of TCS diagnosis among NF1, NF2, and non-NF patients were 12, 16, and 9 years, respectively. The incidence of TCS was 1.2% in NF1 patients and 7.3% in NF2 patients, compared to 0.074% in the general population. The associations of NF incidence with TCS were significantly increased in both NF1 (OR 16.42; 14.38-18.76) and NF2 (OR 105.58; 83.56-133.40) patients compared to the general population. Symptomatic TCS requiring surgical intervention was not significantly associated with NF1/NF2 patients compared to the general TCS population.

CONCLUSION

This analysis demonstrates a high incidence of TCS but delayed intervention in pediatric NF patients. Considering TCS counseling, spinal MRI, and earlier intervention may be warranted for NF patients experiencing musculoskeletal symptomatology.

Barriers to neurosurgery for medical students: a national study focused on the intersectionality of gender and race

OBJECTIVE

Despite 51.2% of medical school graduates being female, only 29.8% of neurosurgery residency applicants are female. Furthermore, only 12.6% of neurosurgery applicants identify as underrepresented in medicine (URM). Evaluating the entry barriers for female and URM students is crucial in promoting the equity and diversity of the neurosurgical workforce. The objective of this study was to evaluate barriers to neurosurgery for medical students while considering the interaction between gender and race.

METHODS

A Qualtrics survey was distributed widely to US medical students, assessing 14 factors of hesitancy toward neurosurgery. Likert scale responses, representing statement agreeability, converted to numeric values on a 7-point scale were analyzed by Mann-Whitney U-test and ANOVA comparisons with Bonferroni correction.

RESULTS

Of 540 respondents, 68.7% were female and 22.6% were URM. There were 22.6% male non-URM, 7.4% male URM, 53.5% female non-URM, and 15.2% female URM respondents. The predominant reasons for hesitancy toward neurosurgery included work/life integration, length of training, competitiveness of residency position, and perceived malignancy of the field. Females were more hesitant toward neurosurgery due to maternity/paternity needs (p = 0.005), the absence of seeing people like them in the field (p < 0.001), and opportunities to pursue health equity work (p < 0.001). Females were more likely to have difficulties finding a mentor in neurosurgery who represented their identities (p = 0.017). URM students were more hesitant toward neurosurgery due to not seeing people like them in the field (p < 0.001). Subanalysis revealed that when students were stratified by both gender and URM status, there were more reasons for hesitancy toward neurosurgery that had significant differences between groups (male URM, male non-URM, female URM, and female non-URM students), suggesting the importance of intersectionality in this analysis.

CONCLUSIONS

The authors highlight the implications of gender and racial diversity in the neurosurgical workforce on medical student interest and recruitment. Their findings suggest the importance of actively working to address these barriers, including 1) maternity/paternity policy reevaluation, standardization, and dissemination; and 2) actively providing resources for the creation of mentorship relationships for both women and URM students in an effort to create a workforce that aligns with the changing demographics of medical graduates to continue to improve diversity in neurosurgery.

Simultaneous versus staged bilateral carpal tunnel release via open and endoscopic surgeries: a retrospective propensity score-matched patient comorbidity analysis

OBJECTIVE

Carpal tunnel syndrome (CTS) presents bilaterally in nearly 60%-70% of affected patients. Bilateral carpal tunnel release (CTR) can be performed in a staged or simultaneous fashion. There remains a limited understanding of the optimal preoperative factors to use for patient selection when determining simultaneous versus staged bilateral CTR. Moreover, it is unclear how these factors influence postoperative outcomes. In this study, the authors aimed to identify and compare preoperative comorbidities and postoperative outcomes in patients who had undergone simultaneous versus staged open and endoscopic bilateral CTR.

METHODS

The authors performed a retrospective analysis of data collected from the TriNetX database. Patients with bilateral CTS who had been treated from February 1, 2002, to February 1, 2022, were dichotomized by their bilateral release approach: simultaneous or staged within 3 months. The resulting groups were analyzed separately by open versus endoscopic techniques. Next, cohorts were analyzed for preoperative comorbidities to identify possible factors for surgical determination. Then, they were propensity score matched on demographics and comorbidities. Postoperative outcomes within 6 months of surgery were measured with and without matching.

RESULTS

After matching, 9286 and 3709 patients remained in the open and endoscopic groups, respectively. Those who had undergone staged surgeries via an open or endoscopic approach had more preoperative comorbidities. After matching, staged open release was associated with significantly higher rates of postprocedural care, hand/joint pain, limb pain, trigger finger, and upper respiratory tract infections. Simultaneous open release was associated with higher rates of emergency room visits. Staged endoscopic release was associated with significantly higher rates of postprocedural care, limb pain, and trigger finger. No significant outcomes were favored in the simultaneous endoscopic group.

CONCLUSIONS

Before matching, patients who had undergone staged CTR had significantly higher rates of preoperative medical comorbidities compared with patients in the simultaneous CTR group. Moreover, staged CTR was significantly associated with higher rates of postoperative complications. After matching on demographics and comorbidities, staged CTR was still associated with higher rates of postoperative complications, suggesting that preoperative comorbidities do not influence postoperative outcome. Further prospective studies could be used to validate these results and provide new findings for the management and treatment of these groups.

Systematic Review of Cerebrospinal Fluid Biomarker Discovery in Neuro-Oncology: A Roadmap to Standardization and Clinical Application

Effective diagnosis, prognostication, and management of CNS malignancies traditionally involves invasive brain biopsies that pose significant risk to the patient. Sampling and molecular profiling of cerebrospinal fluid (CSF) is a safer, rapid, and noninvasive alternative that offers a snapshot of the intracranial milieu while overcoming the challenge of sampling error that plagues conventional brain biopsy. Although numerous biomarkers have been identified, translational challenges remain, and standardization of protocols is necessary. Here, we systematically reviewed 141 studies (Medline, SCOPUS, and Biosis databases; between January 2000 and September 29, 2022) that molecularly profiled CSF from adults with brain malignancies including glioma, brain metastasis, and primary and secondary CNS lymphomas. We provide an overview of promising CSF biomarkers, propose CSF reporting guidelines, and discuss the various considerations that go into biomarker discovery, including the influence of blood-brain barrier disruption, cell of origin, and site of CSF acquisition (eg, lumbar and ventricular). We also performed a meta-analysis of proteomic data sets, identifying biomarkers in CNS malignancies and establishing a resource for the research community.

Training Program Factors Most Important to Women When Selecting an Otolaryngology Residency

OBJECTIVES

The aim of the study was to determine factors that female resident physicians find most influential when choosing an otolaryngology residency program.

METHODS

A three-part survey was sent to current female otolaryngology residents via email evaluating the importance of 19 characteristics impacting program choice. The 19 factors were scored from 1 (least important) to 5 (most important). The participants also ranked their personal top five most influential factors. Data were analyzed using descriptive statistics.

RESULTS

One-hundred and fifty of 339 contacted residents participated. Most were aged 30-39 (63%), white (70%), and married (43%). Eighty-five percent had no children, and 52% did not plan to have children during residency. The highest scoring factors derived from Likert scale ratings included resident camaraderie (4.5 ± 0.8), resident happiness (4.4 ± 0.8), and case variety/number (4.4 ± 0.8). The lowest scoring factors were number of fellows (2.9 ± 1.1), attitudes toward maternity leave (2.7 ± 1.3), and maternity leave policies (2.4 ± 1.2). The top five most influential factors and the percentage selecting this were resident camaraderie (57%), resident happiness (57%), academic reputation (51%), case variety/number (47%), and early surgical/clinical experience (44%). Gender-specific factors were infrequently selected. However, 51 (34%) ranked at least one gender-specific factor within their top five list.

CONCLUSION

Non-gender-related factors, like resident camaraderie and surgical experiences, were most valued by women. Conversely, gender-specific factors were less critical and infrequently ranked. Ninety-nine residents (64%) rated exclusively gender-neutral characteristics in their top five list of most influential factors. Our data offer insight into program characteristics most important to female otolaryngology residents, which may assist residency programs hoping to match female applicants.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:600-606, 2024.

Urology Match: Important Factors Women Consider When Choosing a Residency Training Program

OBJECTIVE

To determine factors that women urology resident physicians rate as most influential when selecting residency programs.

METHODS

Surveys were emailed to female urology residents during the 2021-2022 academic year. Residents scored 19 factors influencing residency program choice from 1 "least" to 5 "most" important and ranked their top 5 most influential factors. Data were analyzed via descriptive statistics and quantile regression.

RESULTS

One hundred thirty-six (37%) of 367 female urology residents who received the survey participated. Eighty-two percent had no children and 57% did not plan to have children during residency. The three highest scoring factors derived from Likert scale ratings were resident camaraderie (4.6 ± 0.5 [mean ± SD]), resident happiness (4.6 ± 0.6), and case variety/number (4.4 ± 0.8). As a whole, the lowest scoring characteristics were attitudes toward maternity leave (2.6 ± 1.2) and maternity leave policies (2.5 ± 1.2). Married residents were more likely than those who were single and engaged/in a committed relationship to rank attitudes and policies toward maternity leave as more important (3 vs 2 vs 2, P <.0001). Residents with children were more likely than those without children to rank maternity leave policies as more important (3 vs 2, P <.0001).

CONCLUSION

As a whole, women urology residents prioritized non-gender-related factors. However, gender-specific factors were rated highly by married residents and those with children or planning to have children. Urology training programs may use these results to highlight desirable characteristics to aid recruitment of female residents.

Career satisfaction in women surgeons: A systematic review and meta-analysis

BACKGROUND

Career satisfaction among women surgeons have been well-reported in literature. This study provides a comprehensive review to understand career satisfaction and its contributory factors among female surgeons.

METHODS

PRISMA guidelines were utilized to extract studies for systematic review and meta-analysis. Outcomes assessed included surgical career satisfaction, career reconsideration, work-life balance, and gender bias and discrimination (GBD). Odds ratios were calculated comparing women to men for each outcome.

RESULTS

This study demonstrated that female surgeons were less likely to endorse overall career satisfaction (OR, 0.68; 95% CI, 0.55-0.85) and work-life balance satisfaction (OR, 0.61; 95% CI, 0.40-0.92) compared to male surgeons. It also revealed that women surgeons were more likely to report workplace GBD (OR, 13.82; 95% CI, 4.37-43.65).

CONCLUSIONS

Future interventions may be necessary to increase career and work-life balance satisfaction among women surgeons while reconciling the need to ensure they are adequately informed of the obligations of a surgical career.

Awake craniotomies in the pediatric population: a systematic review

OBJECTIVE

Awake craniotomy (AC) is employed to maximize tumor resection while preserving neurological function in eloquent brain tissue. This technique is used frequently in adults but remains poorly established in children. Its use has been limited due to concern for children's neuropsychological differences compared with adults and how these differences may interfere with the safety and feasibility of the procedure. Among studies that have reported pediatric ACs, complication rates and anesthetic management vary. This systematic review was performed to comprehensively analyze outcomes and synthesize anesthetic protocols of pediatric ACs.

METHODS

The authors followed PRISMA guidelines to extract studies that reported AC in children with intracranial pathologies. The Medline/PubMed, Ovid, and Embase databases were searched from database inception to 2021, using the terms ("awake") AND ("Pediatric*" OR "child*") AND (("brain" AND "surgery") OR "craniotomy"). Data extracted included patient age, pathology, and anesthetic protocol. Primary outcomes assessed were premature conversion to general anesthesia, intraoperative seizures, completion of monitoring tasks, and postoperative complications.

RESULTS

Thirty eligible studies published from 1997 to 2020 were included that described a total of 130 children ranging in age from 7 to 17 years who had undergone AC. Of all patients reported, 59% were male and 70% had left-sided lesions. Procedure indications included the following etiologies: tumors (77.6%), epilepsy (20%), and vascular disorders (2.4%). Four (4.1%) of 98 patients required conversion to general anesthesia due to complications or discomfort during AC. In addition, 8 (7.8%) of 103 patients experienced intraoperative seizures. Furthermore, 19 (20.6%) of 92 patients had difficulty completing monitoring tasks. Postoperative complications occurred in 19 (19.4%) of 98 patients and included aphasia (n = 4), hemiparesis (n = 2), sensory deficit (n = 3), motor deficit (n = 4), or others (n = 6). The most commonly reported anesthetic techniques were asleep-awake-asleep protocols using propofol, remifentanil or fentanyl, a local scalp nerve block, and with or without dexmedetomidine.

CONCLUSIONS

The findings of this systematic review suggest the tolerability and safety of ACs in the pediatric population. Although pediatric intracranial pathologies pose etiologies that certainly may benefit from AC, there is a need for surgeons and anesthesiologists to perform individualized risk-benefit analyses due to the risks associated with awake procedures in children. Age-specific, standardized guidelines for preoperative planning, intraoperative mapping, monitoring tasks, and anesthesia protocols will help to continue minimizing complications, while improving tolerability, and streamlining workflow in the treatment of this patient population.

Early Celecoxib use in Patients with Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) can cause rapid brain inflammation. There is debate over the safety and efficacy of anti-inflammatory agents in its treatment. With a particular focus on cyclooxygenase 2 (COX2) selective inhibition, we sought to determine the impact of celecoxib versus no celecoxib treatment on outcomes in patients with TBI and compare these with outcomes associated with nonselective COX inhibition (ibuprofen) and corticosteroid (dexamethasone) treatment.

METHODS

This retrospective cohort study used TriNetX, a large publicly available global health research network, to gather clinical data extracted from the electronic medical records. Using International Classification of Diseases, Tenth Revision and pharmacy codes, we identified patients with TBI who were and were not treated with celecoxib, ibuprofen, and dexamethasone. Analysis was performed on propensity-matched and unmatched cohorts, which were matched on demographics, comorbidities, and neurological injuries. Our primary end point was 1-year survival. Secondary end points were ventilator and tracheostomy dependence, gastrostomy tube placement, seizures, and craniotomy.

RESULTS

After propensity score matching, a total of 1443 patients were identified in both the celecoxib and no celecoxib cohorts. Ninety-two (6.4%) patients in the celecoxib cohort died within 1 year following TBI versus 145 (10.0%) in the no celecoxib cohort (odds ratio 0.61; 95% confidence interval 0.46-0.80; p = 0.0003). The 1-year survival rate was 96.1% in the celecoxib cohort versus 93.1% in the no celecoxib cohort (p < 0.0001). At the end of the 1-year period, celecoxib was associated with significantly lower gastrostomy tube dependence (p = 0.017), seizure activity (p = 0.027), and myocardial infarction (p = 0.021) compared with the control cohort. Ibuprofen was also associated with higher 1-year survival probability and lower rates of post-TBI complications. Dexamethasone was broadly associated with higher morbidity but was associated with higher 1-year survival probability compared with the no dexamethasone cohort.

CONCLUSIONS

Early celecoxib and ibuprofen use within 5 days post TBI was associated with higher 1-year survival probabilities and fewer complications. With emerging yet controversial preclinical evidence to suggest that COX inhibition improves TBI outcomes, this population-level study offers suggestive support for these drugs' clinical benefit, which should be pursued in prospective clinical studies.

Seq-ing the SINEs of central nervous system tumors in cerebrospinal fluid

It is often challenging to distinguish cancerous from non-cancerous lesions in the brain using conventional diagnostic approaches. We introduce an analytic technique called Real-CSF (repetitive element aneuploidy sequencing in CSF) to detect cancers of the central nervous system from evaluation of DNA in the cerebrospinal fluid (CSF). Short interspersed nuclear elements (SINEs) are PCR amplified with a single primer pair, and the PCR products are evaluated by next-generation sequencing. Real-CSF assesses genome-wide copy-number alterations as well as focal amplifications of selected oncogenes. Real-CSF was applied to 280 CSF samples and correctly identified 67% of 184 cancerous and 96% of 96 non-cancerous brain lesions. CSF analysis was considerably more sensitive than standard-of-care cytology and plasma cell-free DNA analysis in the same patients. Real-CSF therefore has the capacity to be used in combination with other clinical, radiologic, and laboratory-based data to inform the diagnosis and management of patients with suspected cancers of the brain.

Photodynamic Therapy for Glioblastoma: Illuminating the Path toward Clinical Applicability

Glioblastoma (GBM) is the most common adult brain cancer. Despite extensive treatment protocols comprised of maximal surgical resection and adjuvant chemo-radiation, all glioblastomas recur and are eventually fatal. Emerging as a novel investigation for GBM treatment, photodynamic therapy (PDT) is a light-based modality that offers spatially and temporally specific delivery of anti-cancer therapy with limited systemic toxicity, making it an attractive option to target GBM cells remaining beyond the margins of surgical resection. Prior PDT approaches in GBM have been predominantly based on 5-aminolevulinic acid (5-ALA), a systemically administered drug that is metabolized only in cancer cells, prompting the release of reactive oxygen species (ROS), inducing tumor cell death via apoptosis. Hence, this review sets out to provide an overview of current PDT strategies, specifically addressing both the potential and shortcomings of 5-ALA as the most implemented photosensitizer. Subsequently, the challenges that impede the clinical translation of PDT are thoroughly analyzed, considering relevant gaps in the current PDT literature, such as variable uptake of 5-ALA by tumor cells, insufficient tissue penetrance of visible light, and poor oxygen recovery in 5-ALA-based PDT. Finally, novel investigations with the potential to improve the clinical applicability of PDT are highlighted, including longitudinal PDT delivery, photoimmunotherapy, nanoparticle-linked photosensitizers, and near-infrared radiation. The review concludes with commentary on clinical trials currently furthering the field of PDT for GBM. Ultimately, through addressing barriers to clinical translation of PDT and proposing solutions, this review provides a path for optimizing PDT as a paradigm-shifting treatment for GBM.

Pregnancy in spina bifida patients: a comparative analysis of peripartum procedures and complications

PURPOSE

Spina bifida (SB) is caused by a failure in neural tube closure that can present with lower extremity sensory deficits, paralysis, and hydrocephalus. Medical advances have allowed increased pregnancies among SB patients, but management and pregnancy-associated complications have not been thoroughly investigated. The objective is to delineate peripartum procedures and complications in patients with SB.

METHODS

A national de-identified database, TriNetX, was retrospectively queried to evaluate pregnant SB patients and the general population. Procedures and complications were investigated using corresponding ICD-10 and CPT codes within 1 year of pregnancy diagnosis.

RESULTS

11,405 SB patients were identified and compared to 9,269,084 non-SB patients. SB patients were significantly more likely to undergo cesarean delivery (1.200; 95% CI [1.133-1.271]) and less likely to receive neuraxial analgesia (0.406; 95% CI [0.383-0.431]). Additionally, patients with SB had an increased risk of seizures (3.922; 95% CI [3.529-4.360]) and venous thromboembolism (VTE) (3.490; 95% CI [3.070-3.969]). Risks of preeclampsia and hemorrhage were comparable. SB patients with hydrocephalus and Chiari malformation type 1 (CM-1) or type 2 (CM-2) were compared to patients without these comorbid conditions. This sub-group analysis showed a significantly increased risk of having cesarean deliveries (SB with hydrocephalus: 12.55%, S.B. with CM-1 or CM-2: 12.81% vs. SB without hydrocephalus or CM, 6.16%) and VTE (3.74%, 2.43% vs. 0.81%). There were also increased risks of hemorrhage and seizures and decreased use of neuraxial analgesia, but the sample size was insufficient.

CONCLUSION

SB patients were more likely to undergo cesarean section and exhibit peripartum complications compared to those without SB.

Early costs and complications of first-line low-grade glioma treatment using a large national database: Limitations and future perspectives

Introduction

Diffuse Low-grade gliomas (DLGG, WHO Grade II) are a heterogenous group of tumors comprising 13-16% of glial tumors. While maximal safe resection is endorsed as the best approach to DLGG, compared to more conservative interventions like stereotactic biopsy, the added costs and risks have not been systematically evaluated. The purpose of this study was to better understand the complication rates and costs associated with each intervention.

Methods

A retrospective cohort study using data from the IBM Watson Health MarketScan® Commercial Claims and Encounters database was conducted, using the International Classification of Diseases, Ninth Revision (ICD-9) codes corresponding to DLGG (2005-2014). Current Procedure Terminology, 4th Edition (CPT-4) codes were used to differentiate resection and biopsy cohorts. Inverse weighting by the propensity score was used to balance baseline potential confounders (age, sex, pre-op seizure, geographic region, year, Charleston Comorbidity Index). Complication rates, hospital mortality, readmission, and costs were compared between groups.

Results

We identified 5,784 and 3,635 patients undergoing resection and biopsy, respectively, for initial DLGG management. Resection was associated with greater 30-day complications (29.17% vs. 26.34%; p < 0.05). However, this association became non-significant after inverse propensity weighting (adjusted odds ratio = 1.09; 0.98-1.20). There was no statistically significant difference in unadjusted, 30-day hospital mortality (p = 0.06) or re-admission (p = 0.52). Resection was associated with higher 90-day total costs (p < 0.0001) and drug costs (p < 0.0001). Biopsy was associated with greater index procedure costs (p < 0.0001). Long-term outcomes and evaluation of DLGG subtypes was not possible given limitations in the metrics recorded in MarketScan and lack of specificity in the ICD coding system.

Conclusion

Resection was not associated with an increase in the adjusted complication rate after balancing for baseline prognostic factors. Total costs and drug costs were higher with resection of DLGG, but the index procedure costs were higher for biopsy. This data should help to facilitate prospective health economic analyses in the future to understand the cost-effectiveness, and impact on quality of life, for DLGG interventions. However, the use of large national databases for studying long-term outcomes in DLGG management should be discouraged until there is greater specificity in the ICD coding system for DLGG subtypes.

Female Neurosurgery Residency Program Directors in the United States: A Cross-sectional Descriptive Analysis

BACKGROUND

The residency program director (PD) position is a valued leadership appointment in academic medicine. PDs are responsible for the success of their program and its residents. The objective of this study is to provide a cross-sectional analysis of baseline demographics and academic backgrounds of current neurosurgery program directors.

METHODS

Data was compiled on neurosurgery PDs and their residency programs, as of the end of May 2021, using publicly available resources including Doximity, FREIDA, and Healthgrades. The Mann-Whitney and Fisher exact tests were used for statistical analysis.

RESULTS

Of 113 PDs identified, 91.15% are male (P < 0.01). The majority of PDs (88.5%) received their medical degrees from U.S. medical schools. The average age of current PDs is 54 years, and the average age at appointment was 48 years. Compared to their male counterparts, female PDs are more likely to be younger at appointment (41 vs. 48 years; P = 0.001) and while holding the same position (45 vs. 55 years; P = 0.001). As a result, female PDs experience less time to appointment after residency (8.6 years vs. 14.7 years, P = 0.013). There are no significant differences regarding the gender of the PD and university affiliation, current appointment, completion of a fellowship, and resident gender ratios.

CONCLUSIONS

The position of neurosurgery residency PD is dominated by fellowship-trained men in their late 40s to 50s. The gender ratio of neurosurgery residents is consistent with the underrepresentation of women in this position. With increasing female representation in neurosurgery, more women may assume this leadership position and begin to hasten the gender balance.

NCOG-12. IMPACT OF TUMOR-RELATED SEIZURES ON MENTAL HEALTH DISORDER ORDER IN LOW-GRADE GLIOMA

INTRODUCTION

Majority of LGG patients experience seizures during their disease course, requiring anti-epileptic drugs (AEDs). Frequent seizures negatively impact health-related quality of life (HRQoL). AEDs, moreover, are hypothesized to have mood-modulating effects. As survival for LGG patients has been improving, it is essential that the impact of seizure burden and AEDs on mental health disorders (MHD) be considered. The objective was to measure an association of tumor-related seizures with MHD onset among LGG patients.

METHODS

This retrospective cohort study queried data from the IBM Watson Health MarketScan® Claims and Encounters Database (2005-2014) to identify LGG patients without prior MHD history who experienced glioma-related seizures. Presence of seizures was determined by anti-epileptic drug fills within one year following LGG diagnosis. Patients with new onset of MHDs were identified using ICD-9 codes for MHDs and psychotropic drug fills in the 12 months post-LGG diagnosis period. Unadjusted odds ratios measured associations between seizures and MHD prevalence.

RESULTS

11,458 LGG patients with no history of MHD were included; 1,799 (15.7%) experienced seizures within 12 months of LGG diagnosis. Among them, 494 (27.5%) developed MHD in the post-LGG diagnosis period. Patients who experienced seizures were more likely to develop an MHD compared to patients who did not (OR, 2.19, 95% CI, 1.95–2.47). MHD incidence was significantly associated with female gender (OR, 1.14, 95%, 1.03–1.26) and age range of 35–44 (OR, 1.20, 95%, 1.03–1.39) compared to 18–34.

CONCLUSION

These findings demonstrated that tumor-related seizures were associated with MHD onset. This highlights the burden of seizures and regular AED use on mental health. The psychosocial and neurological aspects related to seizures and AEDs likely contribute to the multifaceted mental health disorder onset seen among these LGG patients. Proactive counseling, diagnosis, and management of MHDs in LGGs, particularly those with seizures, is warranted.

DISP-07. SURVIVAL ANALYSIS OF GLIOBLASTOMA PATIENTS IN PENNSYLVANIA ACCORDING TO AREA DEPRIVATION INDEX AND IDH STATUS

INTRODUCTION

Glioblastoma (GBM) is the most aggressive primary brain tumor with a universally poor prognosis. Living in disadvantaged neighborhoods is associated with poor health outcomes, including increased cancer incidence. This study was designed to elucidate the relationship between GBM patients’ survival, isocitrate dehydrogenase (IDH) mutation status, and residential areas of deprivation in the state of Pennsylvania.

METHODS

Patients from Pennsylvania with a pathological diagnosis of GBM WHO Grade IV between January 2007 and December 2018 were retrospectively reviewed in the Penn State Health database. Demographic variables and molecular features were assessed. Area Deprivation Index (ADI) is a validated measure of regional socioeconomic deprivation that indexes neighborhoods by percentile, with low ADI scores representing less deprivation. Patients were assigned to low ( &lt; 50) or high ( ≥ 51) ADI groups. Survival was measured against IDH status and ADI score; log-rank tests were performed.

RESULTS

121 GBM WHO Grade IV patients were identified (median age at diagnosis: 63, 39.7% female, 60.3% male, 93.4% of white race). Among those, 64 (52.9%) had low ADI, and 57 (47.1%) had high ADI. Patients with high ADI had similar overall survival (OS) rates and progression free survival (PFS) at 18 months (56% OS, 95% confidence interval [CI]: 48-64%; 37.4% PFS, 95%CI: 30-44%; P=0.27) compared to patients with low ADI (50% OS, 95%CI: 43-57%; 32.4% PFS, 95%CI: 26-39%; P = 0.27). Further classification by IDH status resulted in 17 (14%) IDH mutant (IDHm) and 104 (86%) IDH wildtype (IDHwt) patients. Survival analysis demonstrated no significant difference in OS between IDHwt and IDHm patients, regardless of ADI score.

CONCLUSION

The aggressive nature of GBM requires early diagnostic approaches to impact survival. Living in socioeconomic disadvantaged areas may diminish survival outcomes; however, our data indicate that GBM may be too aggressive for ADI to have a significant impact on prognosis.

NCOG-08. IMPACT OF IMMUNOTHERAPY ON PREVALENCE OF BRAIN METASTASES IN MALIGNANT MELANOMA: A REAL-WORLD POPULATION-LEVEL ANALYSIS

INTRODUCTION

Melanoma brain metastases (MBM) are often associated with poor prognosis. Over the last decade, the treatment paradigm for malignant melanoma shifted with the introduction of immunotherapies (ITs), including ipilimumab (ipi) and nivolumab (nivo). Recent clinical trials suggest that IT offers a survival benefit in MBM and may suffice as the sole intervention in those with small, asymptomatic lesions. Secondary trial analyses suggest IT may reduce rates of BM. The goal of this study was to assess the potential impact of IT in reducing prevalence of MBM in a real-world population-level analysis.

METHODS

A retrospective query of TriNetX, a database that collates clinical data from 92 healthcare organizations, was performed. Melanoma patients without brain metastases at diagnosis were stratified as: 1) ipi and nivo (dual-IT), 2) ipi alone (single-IT), or 3) no IT treatment (no-IT). A new diagnosis of MBM, from one month of initiating IT to any time after, was compared among cohorts. Median overall survival (OS) of MBM patients were calculated and compared using Kaplan Meier analysis and log-rank tests.

RESULTS

732,555 melanoma patients were included (717,408 no IT, 4,585 dual-IT, 4,101 single-IT). Mean ages at MBM diagnosis were 66.9, 61.5, and 63.2 years, respectively. MBM prevalence was 1.5%, 9.6%, and 15.6%, for the respective cohorts (p &lt; 0.0001). Dual-IT was associated with a lower rate of MBM compared to single-IT (OR [95%CI], 0.64 [0.61-0.77]). After propensity score matching for age, sex, and comorbidities, median OS were not statistically different between the no-IT, dual-IT, and single-IT cohorts (347, 400, 414 days) for MBM patients.

CONCLUSION

This analysis of real-world data suggests that dual-IT for malignant melanomas decreased the incidence of MBMs compared to single-IT. However, survival outcomes remain comparable once patients succumb to the MBM diagnosis. Prospective studies are underway to look at MBM prevalence given various dual-IT.

DISP-01. IMMUNOTHERAPY ADMINISTRATION RATES IN PATIENTS WITH BRAIN METASTASES: IMPACT OF END STAGE RENAL DISEASE AND DIALYSIS

INTRODUCTION

Comorbid conditions such as end-stage renal disease (ESRD) are common in patients with a diagnosis of brain metastasis (BM). Renal replacement therapy for ESRD patients typically includes hemodialysis or peritoneal dialysis. However, the efficacy of immunotherapy (IT) delivery in dialyzed patients is not well understood. Therefore, treatment modalities for BM and ESRD must be considered during clinical decision-making. This study aimed to determine the rate of IT administration in ESRD patients on dialysis using a network of real-world data.

METHODS

Data were collected from TriNetX (TriNetX, Inc., Cambridge, MA), a research network that provides clinical data access from 92 healthcare organizations globally. The independent variables included ‘secondary malignant neoplasm of brain’, ‘introduction of antineoplastic, monoclonal antibody’, ‘pembrolizumab’, ‘nivolumab’, ‘ipilimumab’, ‘ESRD’, ‘dependence on renal dialysis’ and ‘dialysis services and procedures’. Dialyzed patients were identified as having received dialysis within 3 months before to 5 years after their brain metastases diagnoses. Rates of immunotherapy administration were measured from BM diagnosis and concomitant dialysis use, or the lack thereof.

RESULTS

Two patient cohorts with malignant neoplasms of the brain were identified: a dialyzed cohort of 3,593 patients and a non-dialyzed cohort of 525,831 patients. The dialyzed cohorts’ mean age at index was 64.7 years; 43% were female. Of those, 81 patients received concomitant IT (2.25%). The non-dialyzed cohorts’ mean age at index was 60.7 years; 52% were female. From this cohort, 19,347 patients with BM received IT (3.68%). Patients with BM on dialysis were less likely to receive IT than those not on dialysis (odds ratio: 0.604, 95% confidence interval: 0.484-0.753, P &lt; 0.0001).

CONCLUSION

Patients on dialysis may be selected against as candidates for IT. Given the relative scarcity of patient size and the potential implications of dialysis, prospective studies will be vital to improving IT efficacy in patients with BM.

Neuropharmacological Study of Posaconazole for Glioblastoma: A Phase 0 Clinical Trial Protocol

BACKGROUND

Glioblastoma (GBM) is the most common malignant primary brain tumor with a universally poor prognosis. GBMs express elevated levels of hexokinase 2 (HK2), catalyzing the critical step in glycolysis and influencing several oncogenic pathways. Previous preclinical work has suggested a role for repurposed posaconazole (PCZ) in downregulating HK2 activity, reducing lactate and pyruvate production, interfering with tumor cell metabolism, and increasing mouse survival.

OBJECTIVE

To establish brain tumor penetrance, neuropharmacokinetic profile, and mechanistic effect on tumor cell metabolism of PCZ in adults with GBM.

METHODS

This is an open label, nonrandomized, parallel arm trial involving patients with GBM. Cohorts will receive PCZ (intervention, n = 5) or will not receive PCZ (control, n = 5), followed by tumor resection and microdialysis catheter placement. Dialysate, plasma, and tumor samples will be analyzed for lactate and pyruvate concentrations. Tumor samples will also be assessed for PCZ concentration, HK2 expression, angiogenesis, and apoptosis. PCZ's neuropharmacokinetics will be determined based on the concentration vs time profile and area under the curve 0 to 24 hours of PCZ concentration in the brain interstitium.

EXPECTED OUTCOMES

(1) Increased PCZ concentration in contrast-enhancing brain regions compared with nonenhancing regions; (2) inverse correlation between lactate/pyruvate and PCZ concentrations in dialysate samples from treated patients, over time; and (3) decreased HK2 activity in PCZ-treated tumor samples.

DISCUSSION

A successful trial will support the decision to proceed to advanced phase trials. Any tumor penetration by PCZ, with concomitant effect on glycolysis, warrants further in-depth analysis, as therapeutic options for these deadly tumors are currently limited.

SYST-09 IMPACT OF END-STAGE RENAL DISEASE AND CONCOMITANT DIALYSIS ON THE EFFICACY OF IMMUNOTHERAPY IN BRAIN METASTASES PATIENTS: A PROPENSITY-MATCHED SURVIVAL ANALYSIS

INTRODUCTION

Mounting evidence demonstrates the therapeutic promise of immunotherapies (ITs) for brain metastases (BM). However, there is concern that stringent eligibility criteria in these clinical studies have selected against patients with comorbid conditions. As a result, it remains unclear if these results are truly applicable to the general population, particularly in individuals with end-stage renal disease (ESRD) on dialysis. Therefore, we sought to determine the impact of concomitant dialysis treatment and IT on overall survival (OS) of patients with BM.

METHODS

Data were collected from TriNetX (TriNetX, Inc., Cambridge, MA), a global research network that aggregates clinical data from 92 healthcare organizations. Independent variables included ‘secondary malignant neoplasm of brain’, ‘ipilimumab’, ‘pembrolizumab’, ‘ESRD’, ‘dependence on renal dialysis’, and ‘dialysis services and procedures’. Patients with BM receiving IT were dichotomized by dialysis use. Cohorts were propensity matched on age, gender, and race. Kaplan-Meier analyses and log rank tests were conducted to assess overall survival (OS) and survival probability over a five-year period.

RESULTS

Of the 14,368 confirmed BM patients treated with IT, 95 (0.6%) began dialysis within three months of IT initiation. Propensity matching established 95 patients in each cohort. The dialyzed cohort had a median OS of 277 days with a survival probability of 11.6%, compared to the non-dialyzed group with a median OS of 419 days and survival probability of 40.29% (p=0.109; hazard ratio 1.422, 95% confidence interval, 0.923-2.191, p=0.891). A separate comparison cohort was created to compare ESRD diagnosis with or without dialysis (n=56 and n=106 respectively). The comparison cohorts did not show a difference in median OS and survival probability (p=0.49).

CONCLUSION

Despite their health complexities, individuals with ESRD, with or without dependence on dialysis, may nonetheless derive a similar survival benefit from ITs. Therefore, we advocate for greater inclusion of patients with advanced comorbidities in clinical trials to assess for real-world safety and efficacy outcomes.

SYST-16 PROPENSITY-MATCHED SURVIVAL ANALYSIS OF SECOND AND THIRD GENERATION TYROSINE KINASE INHIBITORS IN THE TREATMENT OF BRAIN METASTASES FROM LUNG CANCER PRIMARY

INTRODUCTION

Brain metastases from lung cancer (BMLC) are common and represent an aggressive form of disease. Numerous ongoing clinical trials are investigating targeted molecular therapies against epidermal growth factor receptor (EGFR), which have demonstrated blood-brain-barrier permeability and intracranial activity. However, there is limited real-world efficacy data on second and third-generation EGFR tyrosine kinase inhibitors (TKI), Afatinib and Osimertinib, for the treatment of BMLC. This study provides a real-world assessment to evaluate the impact of these agents on overall survival (OS) at the population-level.

METHODS

This retrospective cohort study queried data from TriNetX, a multi-institutional de-identified database, aggregating data from 90 U.S. healthcare organizations. Three cohorts were established, consisting of patients with BMLC treated with 1) Osimertinib, 2) Afatinib, or 3) Neither Osimertinib nor Afatinib. Cohorts 1 and 3, as well as cohorts 2 and 3, were propensity matched on demographics and comorbidities. Median overall survival (OS) was compared via Kaplan Meier analyses, using log-rank tests and Cox proportional hazards ratios (HR).

RESULTS

After matching, we identified 1,990 BMLC patients treated with Osimertinib (cohort 1) and 1,990 treated without Afatinib and Osimertinib (cohort 3). Median OS was 21.2 months and 13.5 months for the two cohorts, respectively (p &lt; 0.0001; HR [95% CI], 0.69 [0.63-0.77]). Furthermore, we identified 685 BMLC patients treated with Afatinib (cohort 2) and 685 treated without Afatinib and Osimertinib (cohort 3) after matching. Median OS was 19.0 months and 11.5 months, respectively (p &lt; 0.0185; HR [95% CI], 0.83 [0.71-0.97]).

CONCLUSION

Afatinib and Osimertinib demonstrated a significant survival benefit for patients with BMLC, with comparable, if not better, results to other therapeutic options. These findings suggest strong intracranial efficacy of these agents, while indicating a greater generalizability of the results. Further prospective studies are warranted to better understand their potential role in the BMLC treatment paradigm.

SYST-08 SURVIVAL ANALYSIS OF METASTATIC MELANOMA PATIENTS WITH BRAIN METASTASIS USING SURVEILLANCE, EPIDEMIOLOGY, AND END RESULTS (SEER)

INTRODUCTION: Melanoma brain metastases (BM) are common and are historically associated with poor prognosis. In the early 2010s, the treatment paradigm for malignant metastatic melanoma shifted with the introduction of immunotherapy (IT). Recent studies suggest that IT provides survival benefits for patients with BM from melanoma primary. The goal of this study was to validate these findings in a large population cohort. METHODS: Data were collected from the Surveillance, Epidemiology and End Results (SEER) database, version 8.3.4 (22 March 2017). Three cohorts were created based on the FDA approval date of IT: ipilimumab (2011), nivolumab (2014), and nivolumab plus ipilimumab (2015) for use in metastatic melanomas. Respectively, the cohorts are defined as the pre-IT era cohort (2010), early-IT era cohort (2011-2015) and late-IT era cohort (2016-2018). One-year overall survival (OS), 2-year OS, and median OS were assessed using a Kaplan-Meier analysis and log rank tests. RESULTS: 1,893 patients were included in this analysis (190 in the pre-IT era, 1,021 in the early-IT era, and 682 in the late-IT era) that had histologically confirmed melanoma with secondary BM at diagnosis. Median OS was significantly increased across the pre-, early-, and late-IT era cohorts, respectively, with the largest increase occurring between the early-IT and late-IT eras (1-year OS: 20.6% vs. 17.0% vs. 38.2%, 2-year OS: 10.5% vs. 14.2% vs. 27.1%, and median OS: 5 vs. 6 vs. 8 months, p < 0.001 by log-rank test). CONCLUSION: The introduction of IT for malignant melanomas has significantly improved the survival outcomes of melanoma patients with brain metastasis. Novel treatment paradigms involving IT with other adjuvant therapies need to be explored to further improve intracranial activity in melanoma patients.

Pregnancy and Childbirth in Women With Meningioma

Background Ten percent of women of childbearing age have histologically confirmed meningioma. To date, little is known regarding pregnancy-related outcomes for women with meningioma. Methods We used a de-identified database network (TriNetX's Research Network, https://trinetx.com/) to gather information on pregnant patients with meningioma (cohort 1) versus pregnant patients without meningioma (cohort 2). The primary outcome of interest included the impact of meningioma on mortality at one year. Secondary endpoints included ectopic or molar pregnancy, cesarean section, abortion, preterm labor, depression, pre-eclampsia/eclampsia, and craniotomy. Odds ratios (OR) with 95% confidence intervals (CI) were used to measure levels of association between each cohort and the outcomes of interest. Results A total of 1,739 patients were identified in each cohort following propensity-score matching. Mortality was seen in 23 patients (1.32%) in cohort 1 versus 26 patients (1.41%) in cohort 2 (OR 0.88, 95% CI {0.50, 1.55}, p=0.66). Ectopic/ molar pregnancy was seen in 31 (1.78%) versus 42 (2.42%) patients in cohorts 1 and 2, respectively (OR 0.73, 95% CI {0.046,1.17}, p=0.19). Cesarean section was seen in 126 (7.25%) versus 164 (9.43%) patients, respectively (OR 0.75, 95% CI {0.59,0.97}, p=0.020). Abortion was seen in 128 (7.36%) versus 183 (10.52%) patients, respectively (OR 0.68, 95% CI {0.53,0.86}, p=0.0011). Preterm labor was seen in 75 (4.31%) versus 119 (6.84%) patients, respectively (OR 0.61, 95% CI {0.46,0.83}, p=0.0012). Depression was seen in 258 (14.84%) versus 270 (15.53%) patients, respectively (OR 0.95, 95% CI {0.79,1.14}, p=0.57). Pre-eclampsia/eclampsia was seen in 3.11% versus 5.52% patients, respectively (OR 0.55, 95% CI {0.39,0.77}, p=0.0005). Craniotomy was seen in 74 (4.26%) versus 0 (0%) patients in cohort 1 and cohort 2, respectively. Conclusion Patients with meningioma were not at higher risk for pregnancy complications, including ectopic/molar pregnancy, cesarean section, abortion, preterm labor, pre-eclampsia/eclampsia, and mortality, compared to their non-meningioma counterparts. Still, coordinated care by neurosurgical and obstetrical providers may benefit women with meningiomas who are planning for pregnancy or are currently pregnant.

Risk factors for cranial irradiation-related late neurocognitive toxicity: A prospective cohort study

2066

Background: Neurocognitive dysfunction is a common complication of cranial irradiation, occurring in up to 50% of irradiated brain tumor patients. Symptoms often severely compromise quality of life long before patients succumb to their tumor; however, risk factors are poorly understood, and consequently, prognostication and prevention have not been possible. The objective of this study was to evaluate the prognostic value of vascular risk factors for the development of irradiation-related brain injury. Methods: This single-institution prospective cohort study included patients with malignant primary brain tumors who received cranial irradiation as part of their initial tumor-directed therapy. Three putative vascular risk factors – homocysteine, total cholesterol, apoprotein E genotype (ApOE) – were measured and dichotomized (above vs. below the laboratory normal). Univariate analyses compared each risk factor with four measures of neurocognitive dysfunction: mini-mental status exam (MMSE), MRI white matter changes at 6 months (MRI), physician (Phys) assessment, and patient (Pat) assessment. Decision analysis was used to construct a prediction algorithm. Results: 80 patients were included in this analysis. Elevated homocysteine was the most powerful and consistent predictor of neurocognitive toxicity, followed by elevated triglycerides and the ApOE genotype (Table). Logistic regression revealed a highly significant (p<0.01) association between homocysteine level and each of the four outcome variables. Decision tree analysis using homocysteine level (high vs. low) and ApoE genotype (yes vs. no) provided the most efficient predictive algorithm. Conclusions: Two putative vascular risk factors (homocysteine level > 14 and ApOE genotype) provide moderate ability to predict post-radiation neurocognitive dysfunction using a variety of simple but clinically meaningful definitions of dysfunction. This predictive algorithm should be validated in prospective trials. If these findings are corroborated, studies examining additional risk factors as well as studies looking at risk factor mitigation will be appropriate. [Table: see text]

Association of Low-Grade Glioma Diagnosis and Management Approach with Mental Health Disorders: A MarketScan Analysis 2005-2014

Simple Summary

Low-grade gliomas (LGGs) comprise 13–16% of glial tumors. As survival for LGG patients has been improving, it is important to consider the effects of diagnosis and treatment on mental health. The aims of this retrospective cohort study were to determine the incidence, prevalence, and risk factors of mental health disorders (MHD) in LGG patients. In our analysis including 20,432 LGG patients, we identified an MHD prevalence of 60.9%. Of those with no history of prior MHD, 16.9% of LGG patients developed a new onset of MHD within 12 months of LGG diagnosis. Risk factors included female gender, ages 35–54, presence of seizures, and first-line surgical treatment. Therefore, proactive surveillance and counseling surrounding MHDs are recommended among LGG patients. Impact of surgery on brain networks affecting mood should also be considered.

Abstract

Low-grade gliomas (LGGs) comprise 13–16% of glial tumors. As survival for LGG patients has been gradually improving, it is essential that the effects of diagnosis and disease progression on mental health be considered. This retrospective cohort study queried the IBM Watson Health MarketScan^® Database to describe the incidence and prevalence of mental health disorders (MHDs) among LGG patients and identify associated risk factors. Among the 20,432 LGG patients identified, 12,436 (60.9%) had at least one MHD. Of those who never had a prior MHD, as documented in the claims record, 1915 (16.7%) had their first, newly diagnosed MHD within 12 months after LGG diagnosis. Patients who were female (odds ratio (OR), 1.14, 95% confidence intervals (CI), 1.03–1.26), aged 35–44 (OR, 1.20, 95% CI, 1.03–1.39), and experienced glioma-related seizures (OR, 2.19, 95% CI, 1.95–2.47) were significantly associated with MHD incidence. Patients who underwent resection (OR, 2.58, 95% CI, 2.19–3.04) or biopsy (OR, 2.17, 95% CI, 1.68–2.79) were also more likely to develop a MHD compared to patients who did not undergo a first-line surgical treatment. These data support the need for active surveillance, proactive counseling, and management of MHDs in patients with LGG. Impact of surgery on brain networks affecting mood should also be considered.